| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
269 |
269 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
313 |
312 |
$8K |
| D1110 |
Prophylaxis - adult |
170 |
165 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
40 |
$8K |
| D1351 |
Sealant - per tooth |
245 |
66 |
$7K |
| D1206 |
Topical application of fluoride varnish |
204 |
204 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
190 |
188 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
34 |
34 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
60 |
56 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
195 |
154 |
$2K |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$888.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
43 |
43 |
$781.30 |